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The Journal of Clinical Psychiatry Apr 2012To perform a meta-analysis of antidepressant-antipsychotic cotreatment versus antidepressant or antipsychotic monotherapy for psychotic depression. (Comparative Study)
Comparative Study Meta-Analysis Review
Are antipsychotics or antidepressants needed for psychotic depression? A systematic review and meta-analysis of trials comparing antidepressant or antipsychotic monotherapy with combination treatment.
OBJECTIVE
To perform a meta-analysis of antidepressant-antipsychotic cotreatment versus antidepressant or antipsychotic monotherapy for psychotic depression.
DATA SOURCES
We performed an electronic search (from inception of databases until February 28, 2011) in PubMed/MEDLINE, Cochrane Library, and PsycINFO, without language or time restrictions. Search terms were (psychosis OR psychotic OR hallucinations OR hallucinating OR delusions OR delusional) AND (depression OR depressed OR major depressive disorder) AND (random OR randomized OR randomly).
STUDY SELECTION
Eight randomized, placebo-controlled acute-phase studies in adults (N = 762) with standardized criteria-defined psychotic depression (including Research Diagnostic Criteria, DSM-III, DSM-IV, or ICD-10) were meta-analyzed, yielding 10 comparisons. Antidepressant-antipsychotic cotreatment was compared in 5 trials with 6 treatment arms (n = 337) with antidepressant monotherapy and in 4 trials with 4 treatment arms (n = 447) with antipsychotic monotherapy.
DATA EXTRACTION
Primary outcome was study-defined inefficacy; secondary outcomes included all-cause discontinuation, specific psychopathology ratings, and side effects. Using random effects models, we calculated relative risk (RR) with 95% confidence intervals (CIs), number-needed-to-treat/harm (NNT/NNH), and effect size (ES).
RESULTS
Antidepressant-antipsychotic cotreatment outperformed antidepressant monotherapy regarding less study-defined inefficacy (no. of comparisons = 6; n = 378; RR = 0.76; 95% CI, 0.59-0.98; P = .03; heterogeneity [I2] = 34%) (NNT = 7; 95% CI, 4-20; P = .009) and Clinical Global Impressions-Severity of Illness scores (no. of comparisons = 4; n = 289; ES = -0.25; 95% CI, -0.49 to -0.02; P = .03; I2 = 0%), with trend-level superiority for depression ratings (no. of comparisons = 5; n = 324; ES = -0.20; 95% CI, -0.44 to 0.03; P = .09; I2 = 10%), but not regarding psychosis ratings (no. of comparisons = 3; n = 161; ES = -0.24; 95% CI, -0.85 to 0.38; P = .45; I2 = 70%). Antidepressant-antipsychotic cotreatment also outperformed antipsychotic monotherapy regarding less study-defined inefficacy (no. of comparisons = 4; n = 447; RR = 0.73; 95% CI, 0.63-0.84; P < .0001; I2 = 0%) (NNT = 5; 95% CI, 4-8; P < .0001) and depression ratings (no. of comparisons = 4; n = 428; ES = -0.49; 95% CI, -0.75 to -0.23; P = .0002; I2 = 27%), while anxiety (P = .11) and psychosis (P = .06) ratings only trended toward favoring cotreatment. All-cause discontinuation and reported side-effect rates were similar, except for more somnolence with antidepressant-antipsychotic cotreatment versus antidepressants (P = .02). Only 1 open-label, 4-month extension study (n = 59) assessed maintenance/relapse-prevention efficacy of antidepressant-antipsychotic cotreatment versus antidepressant monotherapy, without group differences.
CONCLUSIONS
Antidepressant-antipsychotic cotreatment was superior to monotherapy with either drug class in the acute treatment of psychotic depression. These results support recent treatment guidelines, but more studies are needed to assess specific combinations and maintenance/relapse-prevention efficacy.
Topics: Adult; Antidepressive Agents; Antipsychotic Agents; Depressive Disorder, Major; Drug Therapy, Combination; Humans; Psychotic Disorders; Treatment Outcome
PubMed: 22579147
DOI: 10.4088/JCP.11r07324 -
Journal of Critical Care Apr 2012The aim of this study was to review literature exploring the emotional consequences of delirium and delusional memories in intensive care unit patients. (Review)
Review
PURPOSE
The aim of this study was to review literature exploring the emotional consequences of delirium and delusional memories in intensive care unit patients.
METHODS
A systematic review was performed using PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsychINFO.
RESULTS
Fourteen articles were eligible for this review. Five of them assessed delirium during intensive care unit admission, and the remainder assessed delusional memories during or after admission. No association was found for delirium and adverse emotional outcome. Data regarding delusional memories and emotional outcome were heterogenic. Some studies presented worse scores on posttraumatic stress disorder screening tools in patients with delusional memories, whereas other studies found better scores in patients with delirium or delusional memories.
CONCLUSIONS
Based on current literature, no relationship could be shown for delirium and emotional outcome. Regarding delusional memories and adverse emotional outcome, results were in contradiction.
Topics: Delirium; Delusions; Emotions; Humans; Intensive Care Units; Memory; Patient Admission
PubMed: 21958975
DOI: 10.1016/j.jcrc.2011.07.074 -
Psychological Medicine Mar 2011The nosological status of olfactory reference syndrome (ORS) is a matter of debate and there is uncertainty as to what treatments are effective. (Review)
Review
BACKGROUND
The nosological status of olfactory reference syndrome (ORS) is a matter of debate and there is uncertainty as to what treatments are effective.
METHOD
The world literature was searched for reports of cases of ORS. Clinical, nosological and therapeutic information from cases meeting proposed diagnostic criteria for the disorder was summarized and tabulated.
RESULTS
A total of 84 case reports (52 male/32 female) were found. Age of onset was <20 years in almost 60% of cases. Smell-related precipitating events were recorded in 42%. Most patients could not smell the smell or only did so intermittently. Authors of the reports expressed reservations about the delusional nature of the belief in slightly under half of the cases. Over two-thirds were improved or recovered at follow-up, with the disorder responding to antidepressants and psychotherapy more frequently than to neuroleptics.
CONCLUSIONS
ORS is a primary psychiatric syndrome that does not fit well into its current classification as a subtype of delusional disorder, both in terms of its nosology and its response to treatment.
Topics: Adult; Age of Onset; Antipsychotic Agents; Child; Humans; Middle Aged; Olfaction Disorders; Smell; Syndrome; Young Adult
PubMed: 20529415
DOI: 10.1017/S0033291710001091 -
L'Encephale Dec 2009Tragic and high profile killings by people with mental illness have been used to suggest that the community care model for mental health services has failed. It is also... (Review)
Review
INTRODUCTION
Tragic and high profile killings by people with mental illness have been used to suggest that the community care model for mental health services has failed. It is also generally thought that schizophrenia predisposes subjects to homicidal behaviour.
OBJECTIVE
The aim of the present paper was to estimate the rate of mental disorder in people convicted of homicide and to examine the relationship between definitions. We investigated the links between homicide and major mental disorders.
METHODS
This paper reviews studies on the epidemiology of homicide committed by mentally disordered people, taken from recent international academic literature. The studies included were identified as part of a wider systematic review of the epidemiology of offending combined with mental disorder. The main databases searched were Medline. A comprehensive search was made for studies published since 1990.
RESULTS
There is an association of homicide with mental disorder, most particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. However, it is not clear why some patients behave violently and others do not. Studies of people convicted of homicide have used different definitions of mental disorder. According to the definition of Hodgins, only 15% of murderers have a major mental disorder (schizophrenia, paranoia, melancholia). Mental disorder increases the risk of homicidal violence by two-fold in men and six-fold in women. Schizophrenia increases the risk of violence by six to 10-fold in men and eight to 10-fold in women. Schizophrenia without alcoholism increased the odds ratio more than seven-fold; schizophrenia with coexisting alcoholism more than 17-fold in men. We wish to emphasize that all patients with schizophrenia should not be considered to be violent, although there are minor subgroups of schizophrenic patients in whom the risk of violence may be remarkably high. According to studies, we estimated that this increase in risk could be associated with a paranoid form of schizophrenia and coexisting substance abuse. The prevalence of schizophrenia in the homicide offenders is around 6%. Despite this, the prevalence of personality disorder or of alcohol abuse/dependence is higher: 10% to 38% respectively. The disorders with the most substantially higher odds ratios were alcohol abuse/dependence and antisocial personality disorder. Antisocial personality disorder increases the risk over 10-fold in men and over 50-fold in women. Affective disorders, anxiety disorders, dysthymia and mental retardation do not elevate the risk. Hence, according to the DMS-IV, 30 to 70% of murderers have a mental disorder of grade I or a personality disorder of grade II. However, many studies have suffered from methodological weaknesses notably since obtaining comprehensive study groups of homicide offenders has been difficult.
CONCLUSIONS
There is an association of homicide with mental disorder, particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. Most perpetrators with a history of mental disorder were not acutely ill or under mental healthcare at the time of the offence. Homicidal behaviour in a country with a relatively low crime rate appears to be statistically associated with some specific mental disorders, classified according to the DSM-IV-TR classifications.
Topics: Alcoholism; Antisocial Personality Disorder; Comorbidity; Cross-Sectional Studies; Dangerous Behavior; Female; Homicide; Humans; Incidence; Male; Odds Ratio; Risk Factors; Schizophrenia; Schizophrenic Psychology; Substance-Related Disorders; Violence
PubMed: 20004282
DOI: 10.1016/j.encep.2008.10.009 -
The British Journal of Psychiatry : the... Sep 2007Little is known about the treatment of delusional parasitosis with typical and atypical antipsychotics. (Review)
Review
BACKGROUND
Little is known about the treatment of delusional parasitosis with typical and atypical antipsychotics.
AIMS
To evaluate the effectiveness of typical and atypical antipsychotics in primary delusional parasitosis (delusional disorder, somatic type).
METHOD
A systematic review was conducted.
RESULTS
No randomised trials were found and hence we collected the best evidence from 16 other trials and case reports, separating primary from other forms of delusional parasitosis. Studies using typical antipsychotics showed partial or full remission in between 60 and 100% of patients. Analysis of selected patients with primary delusional parasitosis showed that typical and atypical antipsychotics were effective in the majority, but that remission rates did not differ significantly between typical and atypical antipsychotics.
CONCLUSIONS
In the absence of controlled trials there is limited evidence that antipsychotics are effective in primary delusional parasitosis. Rigorous studies are needed to evaluate their effectiveness and to compare typical and atypical antipsychotics directly.
Topics: Antipsychotic Agents; Clinical Trials as Topic; Delusions; Ectoparasitic Infestations; Humans; Treatment Outcome
PubMed: 17766758
DOI: 10.1192/bjp.bp.106.029660 -
The Cochrane Database of Systematic... Jul 2007Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pimozide, formulated in the 1960s, continues to be marketed for the care of people with schizophrenia or related psychoses such as delusional disorder. It has been associated with cardiotoxicity and sudden unexplained deaths. Electrocardiogram monitoring is now required before and during use.
OBJECTIVES
To assess the clinical effects of pimozide for people with schizophrenia, non-affective psychotic mental illness and delusional disorder.
SEARCH STRATEGY
We searched the Cochrane Schizophrenia Group's Register (July 2005).
SELECTION CRITERIA
We sought all relevant randomised clinical trials comparing pimozide with other treatments.
DATA COLLECTION AND ANALYSIS
Working independently, we inspected citations, ordered papers, and then re-inspected and quality assessed the studies and extracted data. For homogeneous dichotomous data, we calculated the relative risk (RR), 95% confidence interval (CI), and, where appropriate, the number needed to treat (NNT) and the number needed to harm (NNH), on an intention-to-treat basis. We calculated weighted mean differences (WMD) for continuous data. We excluded data if loss to follow-up was greater than 50%.
MAIN RESULTS
We found 35 relevant studies (total n=1348), all including people with schizophrenia but none with delusional disorder. 123 people were randomised to pimozide versus placebo. Data suggest that pimozide prevents relapse (2 RCTs, n=66, RR 0.45 CI 0.2 to 0.9, NNT 4 CI 3 to 22). Compared with typical antipsychotic drugs, pimozide has similar efficacy for outcomes of change in global functioning, mental state, relapse and leaving the study early. People allocated to pimozide did not have a higher mortality than those taking other antipsychotic drugs. Pimozide was more likely than typical antipsychotic drugs to cause tremor in the short-term (6 RCTs, n=192, RR 1.6 CI 1.1 to 2.3, NNH 6 CI 3 to 44) and lead to need for antiparkinsonian medication (4 RCTs, n=124, RR 1.8 CI 1.2 to 2.6, NNH 3 CI 2 to 5) than other drugs. In the medium-term, however, pimozide was less likely to cause sedation (5 RCTs, n=231, RR 0.6 CI 0.5 to 0.9, NNH 6 CI 4 to 16).
AUTHORS' CONCLUSIONS
Although there are shortcomings in the data, there is enough overall consistency over different outcomes and time scales to confirm that pimozide is a drug with similar efficacy to other more commonly used antipsychotic drugs such as chlorpromazine for people with schizophrenia. There are no data to support or refute its use for those with delusional disorder.
Topics: Antipsychotic Agents; Humans; Pimozide; Psychotic Disorders; Randomized Controlled Trials as Topic; Schizophrenia; Schizophrenic Psychology
PubMed: 17636692
DOI: 10.1002/14651858.CD001949.pub2 -
The Cochrane Database of Systematic... 2003At least 0.1% of the world's elderly population have a diagnosis of schizophrenia that started late in life and prognosis may be made worse by delay and avoidance of... (Review)
Review
BACKGROUND
At least 0.1% of the world's elderly population have a diagnosis of schizophrenia that started late in life and prognosis may be made worse by delay and avoidance of treatment.
OBJECTIVES
To assess the effects of antipsychotic drugs for elderly people with late-onset schizophrenia.
SEARCH STRATEGY
We searched the Cochrane Schizophrenia Group trials register (September 2002). This register is compiled by methodical searches of BIOSIS, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Dissertation Abstracts, EMBASE, LILACS, MEDLINE, PSYNDEX, PsycINFO, RUSSMED, Sociofile, supplemented with hand searching of relevant journals and numerous conference proceedings. References of all identified studies were also inspected for more trials.
SELECTION CRITERIA
All relevant randomised controlled trials that compared atypical antipsychotic drugs with other treatments for elderly people (at least 80% of whom should be over 65 years of age) with a recent (within five years) diagnosis of schizophrenia or schizophrenia like illnesses such as delusional disorder, schizoaffective disorder, schizophreniform psychosis or paraphrenia.
DATA COLLECTION AND ANALYSIS
All citations were inspected by the principal reviewer (SA) and papers ordered and re-inspected (by IA, NAQ, SP) to ensure reliable selection. Methodological quality of trials would have been assessed using the Cochrane Reviewers' Handbook criteria and data would have been independently extracted. Data were to have been excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the relative risk (RR), 95% confidence interval (CI), and the number needed to treat (NNT) and number needed to harm (NNH), were to have been calculated based on an intention-to-treat basis.
MAIN RESULTS
Electronic searching produced 119 references, 65 of which were selected for examination of the full text. These referred to 38 studies. Not one study met the entry criteria for this review. Most were randomised but involved elderly people with chronic schizophrenia. Four trials involved people with schizophrenia, and did include a minority who suffered from paraphrenia. Outcomes for this sub-group, however, were not reported. One randomised study (n=18) did focus on late onset schizophrenia, but unfortunately the two treatments under evaluation, remoxipride and thioridazine, have both been withdrawn from use.
REVIEWER'S CONCLUSIONS
There is no trial-based evidence upon which to base guidelines for the treatment of late onset schizophrenia. This review highlights the need for good quality controlled clinical trials to address the effects of antipsychotic drugs for this group. Such trials are possible. Until they are undertaken people with late onset schizophrenia will be treated by doctors using clinical judgement and habit to guide prescribing.
Topics: Age of Onset; Aged; Antipsychotic Agents; Humans; Schizophrenia
PubMed: 12804499
DOI: 10.1002/14651858.CD004162 -
The Cochrane Database of Systematic... 2000Pimozide was first formulated in the late 1960s and continues to be marketed for the care of those with schizophrenia or related psychoses such as delusional disorder.... (Review)
Review
BACKGROUND
Pimozide was first formulated in the late 1960s and continues to be marketed for the care of those with schizophrenia or related psychoses such as delusional disorder. Pimozide is generally well tolerated apart from extrapyramidal side effects. It has, however, been associated with cardiotoxicity and sudden unexplained deaths and electrocardiogram monitoring is now required before and during its use.
OBJECTIVES
To assess the effects of pimozide for people with schizophrenia, non-affective psychotic mental illness and delusional disorder in terms of clinical, social and economic outcomes.
SEARCH STRATEGY
Electronic searches of Biological Abstracts (1982-1995), The Cochrane Schizophrenia Group's Register, EMBASE (1980-1995), Janssen-Cilag UK's register of studies (1999), MEDLINE (1966-1995), PsycLIT (1974-1995), hand-searching the references of all included studies and contacting the manufacturers of the compound.
SELECTION CRITERIA
All randomised trials relating to people with schizophrenia, or similar disorders comparing pimozide to other drug treatments were sought. Studies where randomisation was implied rather than stated were included if they did not change the results. Primary outcomes were clinically significant change in global function, mental state, relapse, hospital admission, death, adverse events and acceptability of treatment.
DATA COLLECTION AND ANALYSIS
Studies were selected, rated and data extracted. For dichotomous data Relative Risks (RR) based on a random effects model with 95% confidence intervals (CI) were estimated. The number needed to treat statistic (NNT) was calculated where indicated. Analysis was by intention-to-treat.
MAIN RESULTS
This review currently includes 34 studies focusing on those with schizophrenia, none on people with delusional disorder. Few people have been randomised to pimozide versus placebo. Data from two longer term studies does suggest that the active drug prevents relapse (n=66, RR 0.45 CI 0.24-0.86, NNT 4, CI 3-22) but the confidence interval is wide. Pimozide has similar efficacy to that of typical antipsychotic drugs for the outcomes of change in global functioning, mental state, relapse and leaving the study early. People allocated to pimozide did not have a higher mortality than those taking other antipsychotics. Pimozide was more likely to cause parkinsonian tremor (RR 1.6 CI 1.1-2.3, NNH 6 CI 3-44) and lead to a requirement for antiparkinsonian medication more frequently (RR 1.8, CI 1.2-2.6, NNH 3 CI 2-5) than other drugs. It was, however, less likely to cause sedation (RR 0.38 CI 0.2-0.7, NNH 6 CI 4-16).
REVIEWER'S CONCLUSIONS
Although there are shortcomings in the data there is enough overall consistency, over different outcomes and time scales, to confirm that pimozide is a drug with similar efficacy to other more commonly used antipsychotics such as chlorpromazine for those with schizophrenia. There are no data to support or refute its use for those with delusional disorder.
Topics: Antipsychotic Agents; Humans; Pimozide; Psychotic Disorders; Schizophrenia; Schizophrenic Psychology
PubMed: 10908518
DOI: 10.1002/14651858.CD001949 -
The Cochrane Database of Systematic... 2000Pimozide was first formulated in the late 1960s and marketed for the care of those with schizophrenia or related psychoses such as delusional disorder. (Review)
Review
BACKGROUND
Pimozide was first formulated in the late 1960s and marketed for the care of those with schizophrenia or related psychoses such as delusional disorder.
OBJECTIVES
To assess the effects of pimozide for people with schizophrenia, non-affective psychotic mental illness and delusional disorder in terms of clinical, social and economic outcomes.
SEARCH STRATEGY
Electronic searches of Biological Abstracts (1982-1995), The Cochrane Schizophrenia Group's Register, EMBASE (1980-1995), Janssen-Cilag UK's register of studies (1999), MEDLINE (1966-1995), PsycLIT (1974-1995), hand-searching the references of all included studies and contacting the manufacturers of the compound.
SELECTION CRITERIA
All randomised trials relating to people with schizophrenia, or similar disorders comparing pimozide to other drug treatments were sought. Studies where randomisation was implied rather than stated were included if they did not change the results. Primary outcomes were clinically significant change in global function, mental state, relapse, hospital admission, death, adverse events and acceptability of treatment.
DATA COLLECTION AND ANALYSIS
Studies were selected, rated and data extracted. For dichotomous data Relative Risks (RR) based on a random effects model with the 95% confidence intervals (CI) were estimated. The number needed to treat statistic (NNT) was calculated where indicated. Analysis was by intention-to-treat.
MAIN RESULTS
This review currently includes 34 studies focusing on those with schizophrenia, none on people with delusional disorder. Few people have been randomised to pimozide versus placebo, but data from three longer term studies does suggest that the active drug prevents relapse (RR 0.59 CI 0.4-0.8, NNT 4 CI 2-13). Pimozide has similar efficacy to that of typical antipsychotic drugs for the outcomes of change in global functioning, mental state, relapse and leaving the study early. People allocated to pimozide did not have a higher mortality than those taking other antipsychotics. Pimozide was more likely to cause parkinsonian tremor (RR 1.6 CI 1.1-2.3, NNH 6 CI 3-44) and lead to a requirement for antiparkinsonian medication more frequently (RR 1.8, CI 1.2-2.6, NNH 3 CI 2-5) than other drugs. It was, however, less likely to cause sedation (RR 0.38 CI 0.2-0.7, NNH 6 CI 4-16).
REVIEWER'S CONCLUSIONS
Although there are shortcomings in the data there is enough overall consistency, over different outcomes and time scales, to confirm that pimozide is a drug with similar efficacy to other more commonly used antipsychotics such as chlorpromazine for those with schizophrenia. There are no data to support or refute its use for those with delusional disorder.
Topics: Antipsychotic Agents; Humans; Pimozide; Psychotic Disorders; Schizophrenia; Schizophrenic Psychology
PubMed: 10796672
DOI: 10.1002/14651858.CD001949